COVID-19 Wellness Screening Questionnaire

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Please be advised in an effort to ensure safety and prevent the spread of COVID-19 we ask that when you arrive for your appointment please check in with the front desk. If we are ready to take you in immediately we will do so, otherwise, we kindly ask that you wait in your car or outside until we call you to go in to your treatment. Please remember to wear a mask when entering the clinic.

First name *

Last name *

Do you have a confirmed case of COVID-19 or have had close contact with a confirmed case of COVID-19? *

Yes

Are you required to quarantine by the government?

Yes

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Checkbox if you have any of the following symptoms: *

Fever

New onset of cough

Worsening chronic cough

Shortness of breath

Difficulty breathing

Sore throat

Difficulty swallowing

Decrease or loss of sense of taste or smell

Chills

Worsening or unexplained headaches

Unexplained fatigue/malaise/muscle aches (myalgias)

Nausea/vomiting, diarrhea, abdominal pain

Pink eye (conjunctivitis)

Runny nose/nasal congestion without other known cause

NONE OF THE ABOVE APPLY TO ME

Required

Please be assured that our office has always met the regulations set forth by public health. However, it is possible to contract COVID-19 infection (or any other communicable disease) in any public space. Our office is taking all measures set by public health given COVID-19. However, due to the nature of our treatments, a 6 foot distance is not always possible between our clients and service providers. Re-entering public life comes with some risks that we all must weigh, but we also want you to feel confident that our office is taking every step to keep our customers and staff safe during this difficult time. Clicking "yes" below indicates that the risks involved are accepted, and that consent is given for treatment to be provided at Body & Soul Clinic *

Yes

Submit

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